Clinical Implications of Neuroscience Research in PTSD

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NYAS
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Dispatch: 6-15-2006
CE: IV
Journal
MSP No.
No. of pages: 17
PE: Julia
Clinical Implications of Neuroscience

Research in PTSD
BESSEL A. VAN DER KOLK
Boston University School of Medicine, The Trauma Center, 1269 Beacon Street,
Brookline, Massachusetts, USA
ABSTRACT: The research showing how exposure to extreme stress affects

brain function is making important contributions to understanding the
nature of traumatic stress. This includes the notion that traumatized
individuals are vulnerable to react to sensory information with subcortically initiated responses that are irrelevant, and often harmful, in the
present. Reminders of traumatic experiences activate brain regions that
support intense emotions, and decrease activation in the central nervous
system (CNS) regions involved in (a) the integration of sensory input
with motor output, (b) the modulation of physiological arousal, and (c)
the capacity to communicate experience in words. Failures of attention
and memory in posttraumatic stress disorder (PTSD) interfere with the
capacity to engage in the present: traumatized individuals lose their way
in the world. This article discusses the implications of this research by
suggesting that effective treatment needs to involve (1) learning to tolerate feelings and sensations by increasing the capacity for interoception,
(2) learning to modulate arousal, and (3) learning that after confrontation with physical helplessness it is essential to engage in taking effective
action.
KEYWORDS: PTSD; affect regulation; neuroimaging; meditation; yoga;
HRV; introspection; movement; action; medial prefrontal cortex; autonomic nervous system
The discovery that sensory input can automatically stimulate hormonal secretions and influence the activation of brain regions involved in attention and
memory once again confronts psychology with the limitations of conscious
control over our actions and emotions. This is particularly relevant for understanding and treating traumatized individuals. The fact that reminders of
the past automatically activate certain neurobiological responses explains why
trauma survivors are vulnerable to react with irrational-subcortically initiated
Address for correspondence: B.A. van der Kolk, M.D., Boston University School of Medicine, 1269
Beacon Street, Brookline MA 02446. Voice: 617-247-3918; fax: 617-859-9805.
e-mail: bvanderk@traumacenter.org
C 2006 New York Academy of Sciences.
Ann. N.Y. Acad. Sci. xxxx: 117 (2006).
doi: 10.1196/annals.1364.022
Q1
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ANNALS NEW YORK ACADEMY OF SCIENCES
responses that are irrelevant, and even harmful, in the present. Traumatized
individuals may blow up in response to minor provocations; freeze when frustrated, or become helpless in the face of trivial challenges. Without a historical
context to understand the somatic and behavioral residues from the past, their
emotions appear out of place and their actions bizarre.
Our first neuroimaging study of PTSD1 using a script-driven imagery symptom provocation paradigm demonstrated that imaging studies can help clarify
the underlying neurobiological changes responsible for the problems with reliving, attention, and arousal characteristic of PTSD. Exposed to traumatic
reminders, subjects had cerebral blood flow increases in the right medial orbitofrontal cortex, insula, amygdala, and anterior temporal pole, and in a relative deactivation in the left anterior prefrontal cortex, specifically in Brocas
area, the expressive speech center in the brain, the area necessary to communicate what one is thinking and feeling. This, and subsequent research supporting
those findings24 demonstrated that when people are reminded of a personal
trauma they activate brain regions that support intense emotions, while decreasing activity of brain structures involved in the inhibition of emotions and
the translation of experience into communicable language. These and other
findings related to neuronal activation in response to traumatic reminders have
enormous potential for articulating the targets for effective intervention and
treatment.
BRAIN AS AN ORGAN DEVOTED TO TAKING EFFECTIVE

ACTION
Neuroscience research has provided important new insights into the processing of intense emotions. The laboratories of Antonio Damasio,5 Joseph
LeDoux,6 Jaak Panksepp,7 Steve Porges,8 Rodolfo Llinas,9 and Richie Davidson10 have shown that living creatures more or less automatically respond to
incoming sensory information with relatively stable neuronal and hormonal activation, resulting in consistent action patterns: predictable behaviors that can
be elicited over and over again in response to similar input. Under ordinary
conditions the executive and symbolizing capacities of the prefrontal cortex
can modify these behaviors by providing the ability to observe, know, and
predict by inhibiting, organizing, and modulating those automatic responses.
This allows people to manage and preserve their relationships with their fellow human beings on whom they so profoundly depend for meaning, company,
affirmation, protection, and connection.
At the end of the 19th century the British neurologist John Hughlings Jackson first proposed that the brain is hierarchically organizedfrom the bottom
up. The organism responds to incoming information by automatically activating emotional and arousal systems that stimulate action tendencies that
can be modified by thought. The highest level of integration and coordination
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VAN DER KOLK: CLINICAL IMPLICATIONS OF NEUROSCIENCE RESEARCH
depends on prefrontal activity that allows the organism to flexibly adjust to the
environment. Jackson proposed that the higher nervous arrangements inhibit
(or control) the lower, and thus, when the higher are suddenly rendered functionless, the lower rise in activity.11 A similar trilevel model is also seen in
MacLeans triune brain.12
What makes people unique in the animal kingdom is their flexibility: their
capacity to make choices about how to respond. This flexibility is the result
of the property of the human neocortex to integrate a large variety of different
pieces of information, to attach meaning to both the incoming input and the
physical urges (tendencies) that these evoke, and to apply logical thought to
calculate the long-term effect of their actions. This allows people to continuously discover new ways of dealing with information and to modify their
responses on the basis of the lessons they learn. This accounts for the fact
that human behavior is much more complex than the purely instinctual and
conditioned behavior seen in other species.
However, this capacity to respond in a flexible manner emerges only slowly
during the course of human development and is easily disrupted. Small children
have little control over their crying and clinging when they feel abandoned,
nor do they have much control over showing their excitement when they are
delighted. They depend on their adult caregivers to take action after they signal
their distress. That caregiver needs to figure out what is going on and needs to
change the conditions in order to restore the homeostasis of the child. Throughout the life cycle, the presence of familiar and trusted human beings continues
to have a profound affect on the modulation of autonomic arousal (e.g., see Ref.
8). Children only develop autonomy when they start developing a prefrontal
cortex. This allows them to appraise their internal states and to execute the
actions necessary to restore disturbances in homeostasis. According to Jean
Piaget, the goal of development is decentration: having your emotions, not
being them.
Adults remain prone to automatically engage in relative fixed action
patterns-routine ways of dealing with life that are interrupted when the usual
actions do not achieve the required results. Thwarting activates emotions
signals that something is wrong: feelings of frustration, discouragement, disgust, or rage, which, in turn, either propel people to change their course of
action or to enlist the help of others. People (and animals) execute whatever
action tendency is associated with any particular emotion: confrontation and
inhibition with anger, physical paralysis with fear, physical collapse in response
to helplessness, an inexorable impulse to move toward sources of joy, such as
running toward people one loves, followed by an urge to embrace them, etc.
The rational mind, while able to organize feelings and impulses, does not
seem to be particularly well equipped to abolish emotions, thoughts, and impulses. Neuroimaging studies of human beings in highly emotional states reveal
that intense emotions of fear, sadness, anger, and happiness cause increased activation in subcortical brain regions and significant reductions of blood flow in
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various areas in the frontal lobe.13 This provides a neurobiological understanding of the clinical observation that people usually have difficulty organizing a
modulated behavioral response when they experience intense emotions.
Emotions occur not by conscious choice, but by disposition: limbic brain
structures, such as the amygdala tag incoming stimuli and determine their
emotional significance. Emotional significance, in turn determines the response, what action is taken. In other words, emotional valence decides the
physical reaction of the organism.5 Charles Darwin,14 Ivan Pavlov,15 and
William James16 all noted that the function of emotions is to take physical action. As Roger Sperry, Nobel Prize 1981, said: the brain is an organ
of and for movement: The brain is the organ that moves the muscles. It
does many other things, but all of them are secondary to making our bodies move.17 Sperry claimed that even perception is secondary to movement:
In so far as an organism perceives a given object, it is prepared to respond to
it. . .The presence or absence of adaptive reaction potentialities, ready to discharge into motor patterns, makes the difference between perceiving and not
perceiving.17
Nina Bull,18 Jaak Panksepp,7 Antonio Damasio,5 and others have demonstrated that each particular emotional state automatically activates distinct action tendencies: a programmed sequence of actions that function to help the
organism cope with environmental challenges. NYU neuroscientist Rodolfo
Llinas summarizes the role of the central nervous system (CNS) in generating
action as follows: in order to make its way in the world any activelymoving
creature must be able to predict what is to come and find a way to where it needs
to go. Prediction occurs by the formation of a sensorimotor image, based on
hearing, vision, or touch. This contextualizes theexternal world and compares
it with the existing internal map. The . . . comparison of internal and external
worlds [results in] appropriate action: a movement is made (p.38). People
experience the combinations of sensations and an urge for physical activation
as a physical feeling or an emotion.9
People who suffer from PTSD seem to lose their way in the world. Since at
least 1889 it has been noted that traumatized individuals are prone to respond
to reminders of the past by automatically engaging in physical actions that
must have been appropriate at the time of the trauma, but that are no longer
relevant.19 In the Traumatic Neuroses of War Kardiner20 described how
WWI veterans riding on the New York subway were prone to duck in fear and
behave as if they were back in the trenches when the train entered a tunnel. As
Pierre Janet noticed: traumatized patients are continuing the action, or rather
the attempt at action, which began when the thing happened and they exhaust
themselves in these everlasting recommencements.21
Neuropsychology and neuroimaging research demonstrate that traumatized
individuals have problems with sustained attention and working memory,
which causes difficulty performing with focused concentration, and hence,
with being fully engaged in the present. This is most likely the result of a
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dysfunction of frontalsubcortical circuitry, and deficits in corticothalamic

integration.22,23
Many traumatized children and adults, confronted with chronically overwhelming emotions, lose their capacity to use emotions as guides for effective
action. They often do not recognize what they are feeling and fail to mount
an appropriate response. This phenomenon is called alexithymia,24 an inability to identify the meaning of physical sensations and muscle activation.
Failure to recognize what is going on causes them to be out of touch with
their needs, and, as a consequence, they are unable to take care of them. This
inability to correctly identify sensations, emotions, and physical states often
extends itself to having difficulty appreciating the emotional states and needs
of those around them. Unable to gauge and modulate their own internal states
they habitually collapse in the face of threat, or lash out in response to minor
irritations. Futility becomes the hallmark of daily life.
Psychology and psychiatry, as disciplines, have paid scant attention to the
deficient orientation and action patterns that are triggered by sensory input,
and, instead, tend to narrowly focus on either neurochemistry or emotional
states. They thereby may have lost sight of the forest for the trees: both neurochemistry and emotions are activated in order to bring about action: either
to engage in physical movements to protect, engage, or defend or displaying
bodily postures denoting fear, anger, or depression that invite others to change
their behavior. Pharmacotherapy helps to address some of the neurochemical problems associated with PTSD, thereby helping to modulate some of the
embarrassing and upsetting behaviors and emotions, but drugs seem to not
really be able to correct whatever abnormality underlies these behaviors and
emotions.
When clinicians rediscovered the profound disruptions in the experience of
physical sensations and the automatic activation of fixed action patterns in
traumatized children and adults they found themselves at a loss on how to
address these deficits. One thing was clear: the rational, executive brain, the
mind, the part that needs to be functional in order to engage in the process
of psychotherapy, has very limited capacity to squelch sensations, control
emotional arousal, or change fixed action patterns. The problem that Damasio
articulated had to be solved: We use our minds not to discover facts but to
hide them. One of things the screen hides most effectively is the body, our own
body, by which I mean, the ins and outs of it, its interiors. Like a veil thrown
over the skin to secure its modesty, the screen partially removes from the mind
the inner states of the body, those that constitute the flow of life as it wanders in
the journey of each day. The elusiveness of emotions and feelings is probably
. . . an indication of how we cover to the presentation of our bodies, how much
mental imagery masks the reality of the body (p.28).5
Given that understanding and insight are the main staples of both cognitive behavioral therapy (CBT) and psychodynamic psychotherapy, the principal therapies currently taught in professional schools, the discoveries of
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neuroscience have been difficult to integrate into therapeutic practice. Neither CBT protocols nor psychodynamic therapeutic techniques pay sufficient
attention to the experience and interpretation of disturbed physical sensations
and preprogrammed physical action patterns. Since Joseph LeDoux had shown
that, at least in rats, emotional memories are forever and that the dorsolateral
prefrontal cortex (dlPFC), which is involved with insight, understanding, and
planning for the future, has virtually no connecting pathways to the brain centers that generate and elaborate emotions, the best therapy claimed to offer is
to help people inhibit the automatic physical actions that emotions provoke-
limited extinction, and helping people with anger management and quieting
them down before blowing off the handle, such as by counting to 10 and taking
deep breaths.2
The realization that insight and understanding are usually not enough to
keep traumatized people from regularly feeling and acting as if they are traumatized all over again forced clinicians to explore techniques that offer the
possibility of reprogramming these automatic physical responses. It was only
natural that this would involve addressing awareness of internal sensations
and physical action patterns. The closest mainstream protocolized therapeutic technique that involves such mindfulness currently is dialectical behavior
therapy (DBT).25 However, many non-Western cultures have healing traditions
that activate and use physical movement and breath, such as yoga, chi qong,
and tai chi all of which claim to regulate emotional and physiological states.
In contrast, in the West working with sensation and movement has been fragmented and has stayed outside the mainstream of medical and psychological
teaching. Yet, working with sensation and movement has been extensively explored in such techniques as focusing, sensory awareness, Feldenkrais, Rolfing,
the F.M. Alexander Technique, bodymind centering, somatic experiencing,
Pesso-Boyden psychotherapy, Rubenfeld synergy, Hakomi, and many others.
While each of these techniques involves very sophisticated approaches, the
nature and effects of these practices are not easily articulated and, as Don
Hanlon Johnson26 notes, their meanings are not easily captured in the dominant intellectual categories. The closest integration of mainstream science
and body-oriented therapies occurred when Nico Tinbergen devoted his 1973
Nobel Prize speech to the Alexander technique.
IMMOBILIZATION VERSUS TAKING ACTION

The notion that sensory triggers reinstate hormonal and motoric responses
relevant to the original trauma raises important clinical issues: one of the
most critical factors that renders a situation traumatic is the experience of
physical helplessnessthe realization that no action can be taken to stave off
the inevitable. Trauma can be conceptualized as stemming from a failure of
the natural physiological activation and hormonal secretions to organize an
effective response to threat. Rather than producing a successful fight or flight
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response the organism becomes immobilized. Probably the best animal model
for this phenomenon is that of inescapable shock, in which creatures are tortured without being unable to do anything to affect the outcome of events.27,28
The resulting failure to fight or escape, that is, the physical immobilization,
becomes a conditioned behavioral response.
Joseph LeDoux and his colleagues have demonstrated that the lateral nucleus of the amygdala is the critical anatomical structure in the formation of
conditioned fear memories. This structure, in turn, communicates with the
central nucleus of the amygdala, which distributes its output to brainstem areas that control the response of the autonomic nervous system (ANS), while
connections with the periaqueductal gray region control freezing or immobility, and connections with the paraventricular hypothalamus control endocrine
responses of the hypothalamic-pituitary-adrenal (HPA) axis. LeDoux and his
colleagues showed that animals that respond actively to the threat thereby divert the flow of information from the lateral amygdala to the motor circuits of
the striatum for active coping, preventing the establishment of conditioned endocrine and behavioral responses.29 Interestingly, decreased activation of the
corpus striatum has been found in several neuroimaging studies of PTSD.3,4
LeDoux and his colleagues showed that, in rats, it is possible to redirect
the fear conditioned pathway that is responsible for initiating autonomic and
endocrine reactions and behavioral immobilization. When rats are given the
option of physically escaping from the stimulus they lose their conditioning,
even after a conditioned fear response is well established. This work suggests
that action diverts the flow of information from the lateral nucleus of the amygdala away from the central nucleus to the basal nucleus of the amygdala, which,
in turn projects on motor circuits in the ventral striatum. LeDoux and Gorman
state: By engaging these alternative pathways, passive fear responding is replaced with an active coping strategy. This diversion of information flows away
from the central nucleus to the basal nucleus, and the learning that takes place,
does not occur if the rat remains passive. It requires that the rat take action.
It is learning by doing, a process in which the success in terminating the
conditioned stimulus reinforces the action taken.30
Most traumas occur in the context of interpersonal relationships, which
involve boundary violations, loss of autonomous action, and loss of selfregulation. When people lack sources of support and sustenance, such as is
common with abused children, women trapped in domestic violence, and incarcerated men, they are likely to learn to respond to abuse and threat with
mechanistic compliance or resigned submission. Particularly if the brutalization has been repetitive and unrelenting, they are vulnerable to continue to
become physiologically dysregulated and go into states of extreme hypo- and
hyperarousal, accompanied by physical immobilization. Often, these responses
become habitual, and, as a result, many victims develop chronic problems initiating effective, independent action, even in situations where, rationally, they
could be expected to be able to stand up for themselves and take care of things.
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In our clinic and laboratory we have taken the findings from neuroscience
about the rerouting of conditioned responses by taking effective action very
seriously. Neuroscience research provides the theoretical underpinning of our
work with action-oriented programs with traumatized adolescents and adults,
involving improvisational theater,31 model mugging (in which women who
have been raped are taught self-defense and learn to actively fight of a simulated attack by a potential rapist), and other interventions that involve physical
action.32
AROUSAL MODULATION AND CONTROL OF THE ANS

Describing traumatic experiences in conventional verbal therapy is likely
to activate implicit memories, that is, trauma-related physical sensations and
physiological hyper- or hypoarousal, which evoke emotions, such as helplessness, fear, shame, and rage. When this occurs trauma victims are prone to
feeling that it is still not safe to deal with the trauma and, instead, are likely to
seek a supportive relationship in which the therapist becomes a refuge from a
life self-experience of anxiety and ineffectiveness. Learning to modulate ones
arousal level is essential for overcoming the resulting passivity and dependency.
Damasio draws attention to the fact that: It makes good housekeeping sense
that [the brain] structures governing attention and structures processing emotion should be in the vicinity of one another. Moreover, it also makes good
housekeeping sense that all of these structures should be in the vicinity of
those which regulate and signal body state. This is because the consequences
of having emotion and attention are entirely related to the fundamental business of managing life within the organism, while, on the other hand, it is not
possible to manage life and maintain homeostatic balance without data on the
current state of the organisms body proper.5
The role of the ANS in PTSD has been well studied: threat activates the
sympathetic and parasympathetic nervous systems. Exposure to extreme threat,
particularly early in life, combined with a lack of adequate caregiving responses
significantly affect the long-term capacity of the human organism to modulate the response of the sympathetic and parasympathetic nervous systems in
response to subsequent stress.8 The sympathetic nervous system (SNS) is primarily geared to mobilization by preparing the body for action by increasing
cardiac output, stimulating sweat glands, and by inhibiting the gastrointestinal
tract. Since the SNS has long been associated with emotion, a great deal of
work on the role of the SNS has been collected to identify autonomic signatures of specific affective states. Overall, increased adrenergic activity is
found in about two-thirds of traumatized children and adults.3335
The parasympathetic branch of the ANS not only influences HR independently of the sympathetic branch, but makes a greater contribution to HR,
including resting HR.3638 Vagal fibers originating in the brainstem affect
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emotional and behavioral responses to stress by inhibiting sympathetic influence to the sinoatrial node and promoting rapid decreases in metabolic output
that enable almost instantaneous shifts in behavioral state.8,38,39 The parasympathetic system consists of two branches: the ventral vagal complex (VVC)
and the dorsal vagal complex (DVC) systems. The DVC is primarily associated
with digestive, taste, and hypoxic responses in mammals. The DVC contributes
to pathophysiological conditions including the formation of ulcers via excess
gastric secretion and colitis. In contrast, the VVC has the primary control of
supradiaphragmatic visceral organs including the larynx, pharynx, bronchi,
esophagus, and heart.36,40
The VVC inhibits the mobilization of the SNS, enabling rapid engagement
and disengagement in the environment.41 Deficient vagal modulatory capacity has been well documented in traumatized boys and in school children with
internalizing problems.42,43 Lack of ventral vagal modulation is likely to contribute to the problems that affect regulation and lack of responsiveness to
interpersonal comfort in traumatized individuals.
Power spectral analysis (PSA) of heart rate variability (HRV) provides the
best available means of measuring the interaction of sympathetic and parasympathetic tone, that is, of brainstem regulatory integrity.44 Low HRV has been
associated with anxiety and depression,4548 with coronary vascular disease,
and increased mortality,49 while high HRV is associated with positive emotions50 and resistance to stress.8
PTSD involves a fundamental dysregulation of arousal modulation at the
brain stem level. PTSD patients suffer from baseline autonomic hyperarousal
and lower resting HRV compared to controls, suggesting that they have increased sympathetic and decreased parasympathetic tone.51 When presented
with mental challenges, such as arithmetic tasks people with PTSD show more
arousal and less vagal control over their heart rate.52
Abnormally high baseline HR can result from high tonic sympathetic activity, low tonic parasympathetic activity, or both.53 While pharmacological
control over sympathetic arousal in PTSD has been fairly well studied (see Pitman et al., this volume; Saxe et al., this volume) the parasympathetic branch
of the ANS has an independent and greater influence on basal HR than the
sympathetic branch, and has been specifically implicated in cardiovascular risk
factors, disease processes, and outcomes. In a recent study we found strong
inverse relationships between heart rate and HRV in individuals with PTSD.
A substantial proportion of PTSD patients did not have elevated basal HRs.
In patients with elevated HR, there clearly was a parasympathetic contribution
independent of the SNS, which supports the notion that poor vagal tone may
play a significant role in PTSD.54
It seems that, in order to come to terms with the past it may be essential to
learn to regulate ones physiological arousal. Currently, little is known about
how people can learn to do that, even though a number of techniques claim to
be able to help people control their HRV. However, no study has been published
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to date to show how changing HRV affects PTSD symptomatology. Since lack
of arousal modulation is such a dominant issue in traumatized individuals we
decided to systematically study whether (1) there might be an effective way
of increasing HRV and (2) whether increased HRV would be associated with
improvement in PTSD symptomatology. Since yoga is a very common practice
for self-care in our culture, and since numerous yoga websites claim that yoga
can change HRV, we decided if we could verify that claim (we could find no
studies to support the notion that yoga, in fact, changes HRV). 1
In order to test the proposition that yoga can change HRV we built a custom
version of the MEDAC System/3 (NeuroDyne Medical Corporation, Cambridge, MA, USA) that allowed eight subjects to be monitored simultaneously
for HRV. Data were sampled at 250 samples per sec and the interbeat interval (IBI) determined. Normalization of IBI values was carried out using the
standard algorithms in the Log-a-Rhythm HRV analysis software, version 3.0
(Nian-Crae, Inc., Cambridge, MA, USA). The normal control yoga group (N
= 11) significantly changed HRV over eight sessions of hatha yoga: paired
samples t-tests were conducted to examine the effects of yoga on HRV. There
was a mean improvement in SDNN of 12.8, (SD = 16.8; t(8) = 2.287; P
0.05). Yoga significantly improved PTSD symptomatology, as measured by
the CAPS: total prepost yoga t(10) = 4.052; P 0.01; CAPS reexperiencing
prepost yoga t(10) = 0.5.164; P 0.001 and CAPS avoidance prepost yoga
t(10) = 2.620; P 0.01. Hyperarousal was nonsignificant in the t-tests)When
measuring HRV from session to session the yoga exhibited a large number of
movement artefacts during the yoga relaxation phase (Shavasana) throughout
the active treatment phase, as well as significant peripheral vasoconstriction,
which interfered with getting accurate readings of HRV in this group. This suggests that the PTSD group had muscular and vascular concomitants of PTSD
that interfered with the measurement of HRV peripherally.
In another pilot study eight female patients between the ages of 25 and 55
years with PTSD were randomly assigned to eight sessions of group therapy
based on DBT or to 75 min of simple hatha yoga exercises, and rated by
rating on the following outcome measures: Davidson PTSD Scale, the PANAS,
and Trauma Center Body Awareness Scale. Samples t-tests were conducted
to examine the effects of yoga and DBT on various symptoms of PTSD. In
comparison with DBT only the yoga group showed significant decreases in
frequency of intrusions and severity of hyperarousal symptoms between time1
and time 2 (t(6) = 3.44; P < 0.05; t(6) = 3.2; P < 0.05, respectively).There are
no significant increases or decreases in these-these numbers mean that they
are related prepost, but say nothing about significant increase and decreasethe t-tests reveal no significant changes for PANAS or body awareness
1 The author gratefully acknowledges the research support of the Creative Care Foundation for this
study, and the contributions of Stefanie Smith, Ali Kozlowski, and Bruce Mehler, and of David Emerson
and the yoga teachers of the Black Lotus project.
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11
The subjective reports of the yoga PTSD group were intriguing; members
of the group made statements, such as: I have always hated my body and I
learned how to take care of it, Having grown up obese and self-conscious
it was wonderful to be able to move gently, I learned to be able to focus
and sense where my body was, I was able to go shopping and know what I
needed, and I learned for the first time how to focus.
MINDFULNESS AND INTEROCEPTION

One of the most robust findings of the neuroimaging studies of traumatized people is that, under stress, the higher brain areas involved in executive
functioning: planning for the future, anticipating the consequences of ones actions, and inhibiting inappropriate responses, become less active. Specifically,
neuroimaging studies of people with PTSD have found decreased activation of
the medial prefrontal cortex (mPFC).55,56 The medial prefrontal comprises anterior cingulate cortex (ACC) and medial parts of the orbitofrontal prefrontal
cortices.57 (See chapter 20 in this volume; see also Ref. 58.) The anterior
cingulate (ACC) specifically has consistently been implicated in PTSD (see
chapters xx, xx, this volume.). The ACC plays a role in the experiential aspects of emotion, as well as in the integration of emotion and cognition. It
has extensive connections with multiple brain structures, including the hypothalamus, amygdala, and brain stem autonomic nuclei. Thus, the ACC is
part of a system that orchestrates the autonomic, neuroendocrine, and behavioral expression of emotion and may play a key role in the visceral aspects
of emotion.58 The mPFC plays a role in the extinction of conditioned fear
responses by exerting inhibitory influences over the limbic system, thereby
regulating the generalization of fearful behavior,59 by attenuating peripheral
sympathetic and hormonal responses to stress,57,60,61 and in the regulation
of the stress hormone cortisol by suppressing the stress response mediated
by the HPA axis.63 Hence, dysfunction of the mPFC is likely to contribute
to the arousal dysregulation in PTSD.22 The fact that the mPFC can directly influence emotional arousal has enormous clinical significance, since it
suggests that activation of interoceptive awareness can enhance control over
emotions.
Clinical experience shows that traumatized individuals, as a rule, have great
difficulty attending to their inner sensations and perceptionswhen asked to
focus on internal sensations they tend to feel overwhelmed, or deny having
an inner sense of themselves. When they try to meditate they often report
becoming overwhelmed by being confronted with residues of trauma-related
perceptions, sensations, and emotions:63 they report of feeling disgusted with
themselves, helpless, panicked, or experiencing trauma-related images and
physical sensations. Trauma victims tend to have a negative body image
as far as they are concerned, the less attention they pay to their bodies, and
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thereby, their internal sensations, the better. Yet, one cannot learn to take care
of oneself without being in touch with the demands and requirements of ones
physical self. In the field of trauma treatment a consensus is emerging that, in
order to keep old trauma from intruding into current experience, patients need
to deal with the internal residues of the past. Neurobiologically speaking: they
need to activate their mPFC, insula, and anterior cingulate by learning to tolerate orienting and focusing their attention on their internal experience, while
interweaving and conjoining cognitive, emotional, and sensorimotor elements
of their traumatic experience.
Sarah Lazar and colleagues at the Massachusetts General Hospital recently
completed an fMRI imaging study of 20 people engaged in meditation involving sustained mindful attention to internal and external sensory stimuli and
nonjudgmental awareness of present-moment stimuli without cognitive elaboration.64 They found that brain regions associated with attention, interoception,
and sensory processing were thicker in meditation participants than matched
controls, including the prefrontal cortex and right anterior insula. The largest
between-group difference was in the thickness of right anterior insula. It has
been proposed that by becoming increasingly more aware of sensory stimuli
during formal practice, meditation practitioners gradually increase their capacity to navigate potentially stressful encounters that arise throughout the day.
Lazar concludes that this Eastern philosophy of emotion is in line with Damasios theory that connections between sensory cortices and emotion cortices
play a crucial role in adaptive decision making.
Lazars study lends support to the notion that treatment of traumatic stress
may need to include becoming mindful: that is, learning to become a careful
observer of the ebb and flow of internal experience, and noticing whatever
thoughts, feelings, body sensations, and impulses emerge. In order to deal with
the past, it is helpful for traumatized people to learn to activate their capacity
for introspection and develop a deep curiosity about their internal experience.
This is necessary in order to identify their physical sensations and to translate
their emotions and sensations into communicable languageunderstandable,
most of all, to themselves.
Traumatized individuals need to learn that it is safe to have feelings and
sensations. If they learn to attend to inner experience they will become aware
that bodily experience never remains static. Unlike at the moment of a trauma,
when everything seems to freeze in time, physical sensations and emotions are
in a constant state of flux. They need to learn to tell the difference between
a sensation and an emotion (How do you know you are angry/afraid? Where
do you feel that in your body? Do you notice any impulses in your body to
move in some way right now?). Once they realize that their internal sensations
continuously shift and change, particularly if they learn to develop a certain
degree of control over their physiological states by breathing, and movement,
they will viscerally discover that remembering the past does not inevitably
result in overwhelming emotions.
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After having been traumatized people often lose the effective use of fight or
flight defenses and respond to perceived threat with immobilization. Attention
to inner experience can help them to reorient themselves to the present by
learning to attend to nontraumatic stimuli. This can open them up to attending
to new, nontraumatic experiences and learning from them, rather than reliving
the past over and over again, without modification by subsequent information.
Once they learn to reorient themselves to the present they can experiment with
reactivating their lost capacities to physically defend and protect themselves.
CONCLUSION
Interoceptive, body-oriented therapies can directly confront a core clinical
issue in PTSD: traumatized individuals are prone to experience the present with
physical sensations and emotions associated with the past. This, in turn, informs
how they react to events in the present. For therapy to be effective it might be
useful to focus on the patients physical self-experience and increase their selfawareness, rather than focusing exclusively on the meaning that people make of
their experiencetheir narrative of the past. If past experience is embodied in
current physiological states and action tendencies and the trauma is reenacted in
breath, gestures, sensory perceptions, movement, emotion and thought, therapy
may be most effective if it facilitates self-awareness and self-regulation. Once
patients become aware of their sensations and action tendencies they can set
about discovering new ways of orienting themselves to their surroundings
and exploring novel ways of engaging with potential sources of mastery and
pleasure.
Working with traumatized individuals entails several major obstacles. One
is that, while human contact and attunement are cardinal elements of physiological self-regulation, interpersonal trauma often results in a fear of intimacy.
The promise of closeness and attunement for many traumatized individuals
automatically evokes implicit memories of hurt, betrayal, and abandonment.
As a result, feeling seen and understood, which ordinarily helps people to feel
a greater sense of calm and in control, may precipitate a reliving of the trauma
in individuals who have been victimized in intimate relationships. This means
that, as trust is established it is critical to help create a physical sense of control by working on the establishment of physical boundaries, exploring ways
of regulating physiological arousal, in which using breath and body movement
can be extremely useful, and focusing on regaining a physical sense of being
able to defend and protect oneself. It is particularly useful to explore previous
experiences of safety and competency and to activate memories of what it feels
like to experience pleasure, enjoyment, focus, power, and effectiveness, before
activating trauma-related sensations and emotions. Working with trauma is as
much about remembering how one survived as it is about what is broken.
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